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Preventing diabetes and obesity in American Indian communities: the

potential of environmental interventions14

Joel Gittelsohn and Megan Rowan

ABSTRACT

Obesity, diabetes, and other diet-related chronic diseases persist in

American Indians at rates that are significantly higher than those

in other ethnic minority populations. Environmental interventions

to improve diet and increase physical activity have the potential

to improve these health outcomes, but relatively little work has taken

place in American Indian communities. We reviewed the experiences

and findings of the following 3 case studies of intervention trials in

American Indian communities: the Pathways trial, which wasa school-based trial that focused on children; the Apache Healthy

Stores program, which was a food-store program that focused on

food preparers and shoppers; and the Zhiwaapenewin Akinomaage-

win trial, which was a multiinstitutional trial for First Nations adults

that worked with food stores, elementary schools, and health and so-

cial services agencies. All 3 trials showed mixed success. Important

lessons were learned, including the need to focus on supply and de-

mand, institutional and multilevel approaches, and the identification

of institutional bases to sustain programs. Am J Clin Nutr

2011;93(suppl):1179S83S.

INTRODUCTION

American Indian and First and diabetes Nations peoples suffer

from remarkably high rates of obesity and diabetes, and those

rates have been steadily increasing (1, 2). From 1994 to 2004, rates

doubled among American Indians aged


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necessary to investigate these key environmental antecedents to

American Indian nutrition, obesity, and chronic disease. More-

over, interventions are necessary to improve food availability in

these settings.

There are several strategies that can be used to improve access

(pricing and availability) to healthy foods in low-income minority

settings. Within food stores, interventions can decrease the

availability of unhealthy foods (eg, high fat and sugar), increase

the availability of healthy foods (eg, low fat and sugar and highfiber), alter physical features (eg, store layout, refrigeration units,

storage, and shelving), change the setting for the provision of

information (eg, point-of-purchase promotions), and manipulate

prices (1619). Alone or in combination, food storebased

strategies have the potential to affect access (ie, supply) and

point-of-purchase decision making regarding food choices (ie,

demand) and, thus, increase the likelihood of sustainability (16

19). However, the majority of store-intervention programs have

been conducted within supermarkets in large US cities (20, 21).

Few programs have worked with small convenience stores, which

constitute the most common day-to-day food-purchase outlets for

many rural American Indian populations. Environmental inter-

ventions can also change access to foods within neighborhoodsby building new supermarkets, developing farmers markets, and

improving transportation (21, 22). At the policy level, store

standards (eg, limiting the provision of unhealthy foods and the

promotion of those foods), pricing, menu labeling, and zoning

policies have been tested in several high- and middle-income

urban settings but have yet to be trialed in American Indian

communities (2325). Other approaches, such as improving food

networks (eg, distributors, producers, and retailers) and local

production and increasing the content of foods could spur wide-

ranging change that could reach American Indians. In short, little

work has been done to change the food environment in American

Indian communities.

With the use of 3 case studies of intervention trials in AmericanIndian communities, this article addressed the following key

questions:

1) Who are the key stakeholders in environmental interven-

tions in American Indian settings? How can they best be

involved?

2) What approaches, or combination of approaches, to envi-

ronmental change are likely to be most effective in Amer-

ican Indian communities?

3) What are some common lessons learned that can be ap-

plied to environmental intervention programs in other

American Indian communities?

METHODS

We addressed these questions by using a case-study approach

(25). We selected 3 programs that were implemented in varied

geographical settings and that sought to change the food and/or

physical activity environment as a means of addressing the

chronic-disease epidemic. The 3 case studies selected met the fol-

lowing criteria: 1) personal experience and familiarity of the

lead author with the program, 2) peer-reviewed publications that

detailed the formative research, process evaluation, and effect of

intervention trials, and 3) significant components of the in-

tervention sought environmental changes. Our analyses sought

to provide a contextually rich description of each case to permit

cross-case comparisons via pattern matching.

CASE STUDY 1: PATHWAYS TRIALCHANGING THE

SCHOOL FOOD AND PHYSICAL ACTIVITY

ENVIRONMENT

Stakeholder engagement

The Pathways trial was a multicenter intervention trial funded

by the National Heart, Lung, and Blood Institute that sought to

reduce obesity and common psychosocial and behavioral risk

factors in American Indian school children (2634). The trial

took place in 7 American Indian communities from 1993 to 2001

(2634). Key stakeholders included tribal health departments,

tribal administration and members, school administrators and

staff, and school board members who provided approval and

participated in program planning and implementation (2634).

Substantial formative research was conducted to aid in the design

of the intervention (26, 27).

Approach to environmental change

Pathways interventions were centered in elementary schools

and include 4 main components as follows: a specially designed

classroom curriculum for grades 35, changes to the school food

service, an enhanced physical education program, and a family

component (2830). The Pathways trial sought to change the

school food environment by providing training and guidelines for

school food-service workers on how to order, prepare, and serve

foods that were lower in fat compared with usual foods offered

(2830). In addition, teachers were given guidelines on nonfood

rewards as a means of reducing competitive foods within schools

(2830). Materials sent home with children and in-school events

encouraged parents to provide healthy foods at home (2830).

The Pathways trial also sought to change the school activity

environment through an enhanced physical education program on

the basis of the Sports, Play & Active Recreation for Kids

(SPARK) curriculum and including additional noncompetitive

American Indian games (30).

The Pathways process evaluation showed that the program was

implemented with different levels of success depending on the

intervention component (31). The school curriculum and food-

service components were implemented with a high reach and

dose, with improvement in implementation of the food-service

guidelines from year to year of the intervention (31). The physical

activity program was implemented with a high reach but only

a moderate dose because most schools were able to meet target

levels of 3 classes/student/wk but not the ideal dose of 5 classes/wk

(31). The family component was weakly implemented with drops

in rates of family pack return cards that came back and decreased

attendance at school events from year to year as the study

progressed (31).

Program effect

The Pathways trial saw positive changes in psychosocial

measures and improvements in diet associated with the in-

tervention (32, 33). However, no significant improvements were

seen in physical activity levels or in obesity, which was the

primary outcome (32, 33). Although the Pathways trial was

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successful in changing the school environment in American

Indian communities, factors outside schools counter-balanced

those within schools (33, 34). Therefore, changes in the home and

community were not present to adequately support changes in

schools.

CASE STUDY 2: APACHE HEALTHY STORES

PROGRAMCHANGING THE COMMUNITY FOODENVIRONMENT

Stakeholder engagement

The Apache Healthy Stores (AHS) program was a community-

based environmental intervention trial funded by the US De-

partment of Agriculture that sought to increase the availability of

healthy food options in local food stores and increase the pur-

chase and consumption of these foods (3537). The trial took

place in the White Mountain and San Carlos Apache reservations

from 2003 to 2005 (3537). Key stakeholders included tribal

administration and members, store owners and managers, and

tribal health departments, particularly the diabetes prevention

programs (35). Stakeholders contributed to program planning andassisted in the implementation of the program. The intervention

was developed through formative research and an engagement

process that centered on community workshops (35).


The AHS program sought to change the food environment by

working with small and large food stores to increase the range of

healthy options and to promote these foods at the point of

purchase and through community media (36). Trained staff

worked with local stores owners and managers to increase the

stocking of healthy foods that were selected through the com-

munity workshop process (36). These foods were promoted in

stores through interactive sessions, posters, flyers, and small

promotional giveaways (eg, water bottles and food clips) (36).

Community media reinforced key messages through radio

announcements, newspaper articles, and cartoons (36).

At the store level, the program was implemented with a high

level of dose and reach and a moderate to high level of fidelity

(36). At the community level, the AHS program was imple-

mented with a moderate degree of fidelity and dose (36). At the

individual level, cooking demonstrations and taste tests reached

a large number of community members with a high dose (36).

Implementing the AHS program on multiple levels (store,

community, and individual) was challenging and differed be-

tween levels (36). Overall, improvements were seen from start to

finish as program staff monitored, documented, and responded to

barriers to implementation (36, 37).

Program effect

The AHS program was successful in showing improvements in

food-related knowledge, healthy food intentions, and the fre-

quency of healthy food purchasing among the main food preparer

or shopper of studied households (37). Modest improvements in

gram intakes of promoted healthy foods and decreases in less

healthful high-fat, high-sugar foods, were shown in association

with the highest levels of exposure to the intervention (37). The

combination of mass-media activities, in-store signage at the

point of purchase, interactive sessions, and the increased avail-

ability of healthy food options in local stores were responsible for

the success of the intervention (37). The study results confirmed

that trials that seek to change the food environment have the

potential to favorably affect various psychosocial factors, food

consumption, and food-related behaviors that would reduce risk

of obesity and other diet-related chronic diseases. On the other

hand, potential improvements in health outcomes were not

assessed. Therefore, it is possible that improvements in diet weremarginal and not associated with measurable health benefits.

Interventions that engage multiple community settings are likely

to show a broader range of benefits. Finally, the AHS program

was sustained and still continues to operate in one of the 2

American Indian communities by the local diabetes prevention

program.

CASE STUDY 3: ZHIWAAPENEWIN AKINOMAAGEWIN

TRIALCHANGING THE FOOD AND PHYSICAL

ACTIVITY ENVIRONMENT

Stakeholder engagementThe Zhiwaapenewin Akinomaagewin (ZA) trial was a community-

based environmental intervention trial funded by the American

Diabetes Association that combined a food-store intervention

similar to that of the AHS program with a school program similar

to that in the Pathways trial and worked in partnership with staff

of the local health and social services (3842). The trial took

place in 7 First Nations reserves from 2004 to 2006 (3842). Key

stakeholders included band administration, store owners and

managers, school administrators and teachers, and staff of health

and social services (38). The ZA intervention was developed

through formative research and community workshops (38) in

which stakeholders contributed ideas and strategies.


Similar to the AHS intervention, the ZA intervention sought to

change the food environment by working with local food stores to

increase the range of healthy options and to promote these foods

at the point of purchase and through community media (38, 39).

Promotions emphasized interactive sessions in stores, community

centers, and at school events and emphasized taste testing and

healthy cooking demonstrations (38, 39). A key difference be-

tween the ZA and AHS interventions was that, in addition to these

changes in local food stores, a locally developed health curricula

was introduced to students in grades 35 (38, 39). The school

curriculum, which was adapted from a previously successfulprogram (17), reinforced key messages introduced in stores.

Family packs were sent home with students (38, 39). Physical

activity and dietary changes were promoted through the school

program and community activities, including walking groups (38,

39).

School-curricula implementation had moderate fidelity with

63% of lessons delivered as planned. Store activities had mod-

erate fidelity; the availability of all promoted foods was 70%, and

appropriate shelf labels were posted 60% of the time (39).

Cooking demonstrations were performed with a 71% fidelity and

high dose (39). A total of 156 posters were placed in community

locations; radio, cable television, and newsletters were used (39).

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Interviews revealed that the program was culturally acceptable

and relevant, and suggestions for improvement were made (39).

Program effect

Baseline and follow-up data were collected before and after the

9-mo intervention program in schools, stores, and communities

that aimed to improve diet and increase physical activity in adults

(41). Regression analyses indicated a significant change in theknowledge of respondents in intervention communities (P ,

0.019) (41, 42). There was also significant increase in the fre-

quency of healthy food acquisition in respondents in the in-

tervention communities (P , 0.003) (41, 42). However, there

were no significant changes in the physical activity or body mass

index in either the intervention or comparison groups (41, 42).

The ZA program was expanded to additional First Nations re-

serves after completion of the trial.

DISCUSSION AND CONCLUSIONS

As we examined our3 environmental intervention case studies,

several key common patterns emerged. First, American Indianchronic diseaseprevention strategies appeared to be successful

when they functioned at multiple levels, including environmental

and individual levels. An additional pattern was that such pro-

grams sought to change the food and physical activity envi-

ronments by partnering with key local stakeholders such as food

retailers, schools, and other community organizations. With the

use of these strategies, institutional-level intervention compo-

nents promoted healthy dietary and behaviors in a way that

influenced household (eg, food purchasing) and individual food-

related psychosocial factors and behaviors, which ultimately

affected obesity and other diet-related chronic disease. Also, the

interventions directly influenced individual-level behaviors such

as food choices.Second, complementary supply-and-demand approaches were

important components of environmental interventions. Multilevel

approaches were successful in changing diabetes- and obesity-

related psychosocial factors and dietary risk behaviors in each of

the rural Native North American settings addressed in our case

studies. As illustrated by the Pathways trial, the success of en-

vironmental changes in schools hinged on changes, support, and

reinforcement at household and community levels. A change in

any single institution should be complemented by reinforcing

strategies in other institutions or at other levels. The AHS pro-

gram successfully integrated each level of the food environment

in its strategy, and by doing so, the program addressed the

supply and demand needed to produce a significant effect. Theintroduction of key foods addressed the supply, whereas

workshops, interactive sessions, community media, and point-

of-purchase marketing spurred the demand needed to sustain

food supplies without subsidies or external reinforcements.

However, despite this evidence, the majority of food-intervention

programs operated at the store-level only. Other programs sought

to increase demand through nutrition education but did little to

affect availability or supply.

Third, it was important to work in multiple institutions to

achieve high exposure. Other programs have addressed demand

through the media, point-of-purchase displays, and structural

adjustments within stores but failed to extend their communi-

cations efforts to the greater community. The AHS and ZA

programs achieved a high exposure by working with community

leaders, such as local health services and community organ-

izations. These leaders contributed to the design of a setting-

appropriate strategy and helped to extend the program reach

through intertribal dissemination. By working in multiple insti-

tutions, such as schools, food stores, and community events, the

AHS and ZA programs also increased the likelihood of in-

terpersonal contact and reinforced messaging.Finally, it was important to find an appropriate institutional

base to sustain activities. Although addressing demand and

working in multiple institutions provided the necessary mecha-

nisms to produce a program effect, the long-term sustainability

was dependent on the involvement of community partners. This

was especially important in the American Indian communities in

which tribal and local health-service agencies played a significant

role in the health and wellness of community members. As shown

by the AHS and ZA programs, staff of health and social services

could be useful collaborators because they had a vested interest in

changing health behaviors. By engaging staff at the start of the

program, ownership and capacity can be increased, which can be

sustained post-intervention.This review had several limitations:

1) We considered interventions that took place in different

settings and used varying approaches with a varying em-

phasis on changing the food environment, which made

direct comparisons complex. We considered our findings

suggestive and provocative but not conclusive.

2) Our analyses were limited to retail food-store interven-

tions. Environmental interventions could also include the

provision of new supermarkets and farmers markets and

improved transportation.

3) The cases selected did not address other variables within

the food environment that affected the availability andconsumption of retail store food in American Indian set-

tings. Local hunting, farming, and food production and the

external food-distribution chain needed to be analyzed to

determine the sourcing variables that affected food access

(availability and pricing).

4) As noted in our analysis of the Pathways trial, more re-

search was needed to address the factors within the com-

munity that affected food choices. Those community

factors and the associated organizations need to be in-

cluded in future interventions and analyzed for effect.

The environmental intervention showed great promise as

a means to address the high rates of obesity and chronic disease

in American Indian communities. Environmental interventionsprovided opportunities for improved diet and increased physical

activity. Much future work remains. Often, behavior-change

theories do not adequately address the inclusion of environmental

factors as modifiable elements of intervention strategies. We need

refined approaches for modifying the food environment on the

basis of solid evidence. There has been a lack of food-store

interventions in urban American Indian settings where there is

a greater dependence on small stores that lack access to local food

producers. Future work should consider the role of prepared

foods and the prepared-food environment (eg, menus, food-

preparation methods, and pricing) in the American Indian diet

and develop and test pilot interventions that address these

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concerns. Future interventions should also place greater emphasis

on the involvement of community members and organizational

leaders in the development and implementation of interventions.

A community-based approach is key to sustainability and ac-

ceptability. Long-term sustainability is also dependent on sup-

portive policies. However, policy-makers are typically interested

in health outcomes as a measure of the program success. Future

work needs to show the benefits of these programs by including

long-term-effect health assessments.

The authors responsibilities were as followsJG: was the primary inves-

tigator or coinvestigator on all studies reviewed and assisted with the prep-

aration andreview of themanuscript; andMR: performedthe literature review

and drafted the manuscript. Neither of the authors had a conflict of interest.

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